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DEPAKTMENT OF PUBLIC HEALTH 



SCHOOL HYGIENE 







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BOSTON 

WRIGHT & POTTER PRINTING CO., STATE PRINTERS 

32 DERNE STREET 

1920 



Reprinted feom the Commonhealth, Vol. 7, No. 3, 1920. 



:ARY Oh GO.-,:i\LSS 

FEB281921 

documents Division 



Publication of this Document 

approved by the 
Supervisor of Administration. 



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SCHOOL HYGIENE. 



By Merrill Champion, M.D., C.P.H., Director, Division of Hygiene, Massachu- 
setts Department of Public Health. 



IN all the field of public health activity there is surely no corner 
which offers greater returns in the way of health dividends 
than does school hygiene; and yet it must be said with regret 
that there is no program more promising on paper and more disap- 
pointing in execution than is the school hygiene program. 

There are many reasons for this state of affairs. Foremost, is 
the fact that school hygiene is essentially a community responsi- 
bility, and as yet the sense of responsibility of the community for 
the health of the school child is not any too well developed. Next, 
there is still much uncertainty in the minds of many as to whether 
medical school inspection is more properly a function of a school 
committee or of a board of health. Lastly, in Massachusetts, am- 
biguously worded laws and an overdeveloped sense of independence 
on the part of cities and towns have prevented proper co-ordination 
and stimulation of local activity. As the result of all these forces, 
the sum total of medical school inspection in this State has been 
most disappointing. 

A curious haziness exists in the minds of many as to the meaning 
of the term "school hygiene." Hygiene may be defined as the science 
of the preservation of health; school hygiene is the science of the 
preservation of health as it applies to the school child. Conditions 
surrounding the school child cannot be said to be normal. He has 
graduated from the free, nomadic life of the pre-school child into an 
environment of restriction and discipline. It is a period of adjust- 
ment to the treadmill of civilized existence. Physical and mental 
changes are taking place which will have a profound effect upon 
later life. It would seem as if little thought were needed to con- 
vince any one of the desirability of constant supervision of the health 
of the school child. 

In these days when money seems the criterion for so many things 
we can estimate the value placed by the community upon the serv- 
ices of school physicians by a study of salaries paid such officials. 
Studies made in 1915 and 1916 by the State Department of Health 



show that most communities place a very low money value upon 
medical school inspection. Some school physicians are paid as little 
as $10 per year, in spite of the fact that the law calls for an annual 
examination of each school child of a character sufficiently searching 
to detect defects which are likely to prevent the child from taking 
full advantage^ of the educational opportunities offered him. It is 
fatuous to suppose that this service can be obtained for $10 a year 
or ten times that sum, except in our tiniest communities. We can- 
not get something for nothing, whether it be groceries or medical 
service. 

Let us now consider what constitute the essentials of school hy- 
giene. We must have, first, a law under which to work; this may 
be of a permissive nature or mandatory. The latter is the type of 
legislation under which the work is carried on in this State. It 
should be recalled, in passing, that before such a mandatory law 
was enacted, the board of health of the city of Boston, in 1894, un- 
dertook medical school inspection, as did the town of Brookline. 
Other places followed shortly after. Antedating this by many years, 
however, the commission, appointed by the Governor in 1849 to 
make a sanitary survey of the State, recommended that "in erecting 
schoolhouses, churches and other public buildings, health should be 
regarded in their site, structure, heating apparatus and ventilation;" 
and again, that "measures be taken to ascertain the amount of sick- 
ness suffered among the scholars who attend the public schools and 
other seminaries of learning of the Commonwealth." Following the 
latter recommendation, studies were made by Dr. Henry P. Bow- 
ditch of the physical growth of school children in Boston, descrip- 
tions of which may be found in the annual reports of the State Board 
of Health of Massachusetts for the years 1877 and 1879. 

In spite of these excellent beginnings, it was 1906 before legisla- 
tion was enacted upon the subject of school hygiene. In accordance 
with this and subsequent legislation, Massachusetts now has a system 
whereby each city or town is supposed to have adequate medical 
examination for its school children, and adequate instruction in 
hygiene. That the majority of places have neither is a fact not 
sufficiently well recognized. 

It would seem worth while to point out in some detail various 
points in the law under which school inspection is administered. The 
first striking fact is that the law is mandatory and applies to every 
city and town in the State. The examination provided for must be 
sufficiently thorough "to ascertain whether he [the pupil] is suffering 
from defective sight or hearing or from any other disability or defect 
tending to prevent his receiving the full benefit of his school work or 



requiring a modification of the school work in order to prevent injury 
to the child or to secure the best educational results." This, it is 
easily seen, calls for medical school examinations and not medical 
inspection. 

A second point to be noted is that although school physicians are 
provided for in the act, no mention is made of the school nurse — 
obviously because school nurses were almost unknown in 1906. 

A third and most fundamental point is that the work is really left 
in the hands of the local authorities with practically no State super- 
vision. Theoretically this is an ideal plan, calculated to get the 
utmost out of community interest and pride. Practically, however, 
the result has been an utter lack of co-ordination, so that we have 
as many types of administration of this law as we have cities and 
towns in the Commonwealth. 

Fourthly, provision is made for safeguarding the child about to 
go into industry. The system of working certificates whereby the 
child before going to work must bring to the school a promise of 
employment, and must pass a physical examination to determine 
his fitness for the job in question, seems well calculated to protect 
the child. In practice, however, the results have been extremely 
poor. Outside of Boston these certificates have, for the most part, 
been handed out indiscriminately, as is shown by the percentage of 
rejections of those examined. Cities have reported as many as 
2,000 examinations for working papers without a single rejection for 
physical defect — manifestly a ridiculous result. The rejections 
should probably be at least 4 or 5 per cent or more. A factor in 
this result is undoubtedly that advantage has been taken of that 
provision of the law which allows the acceptance of certificates from 
private physicians who get paid little or nothing for the work. Un- 
der such conditions the temptation to shirk is well-nigh overwhelm- 
ing. It must be said, however, that the record of the underpaid but 
regularly appointed school physician in many places is scarcely better. 

The fifth point to be noted is one already referred to and which 
has been and is the subject of much controversy. The Massa- 
chusetts law provides that the school physician shall be appointed 
by the school committee in all towns, and in such cities as do not 
have the medical school inspection carried on by the board of health. 

It must be acknowledged that much can be said for this plan. 
In the first place, it is argued that as medical school inspection con- 
cerns the school child, and is carried on in the school, to avoid con- 
fusion it ought to be under the school authorities. Again, it is 
pointed out that the school committees have a full-time agent in the 
person of the superintendent, while the average board of health 



6 

does not have any such full-time agent. This is at present a good 
argument, though it is becoming increasingly less so as boards of 
health take their jobs more seriously and are taken more seriously 
by the communities they serve. On the other hand, much may be 
said in favor of board of health control. The community interest 
in the health of the individual centers in the board of health. It is 
not very logical to single out a few years in the life of the individual, 
and to say that during this time he is to be considered as apart 
from other human beings younger and older than himself, and there- 
fore must have his health needs supervised by a separate body. 

Further objections to school committee control of medical school 
examinations are that the control of communicable disease — an 
important factor in medical school supervision — is vested by law 
in the board of health, and in it alone; and that under the law the 
school committee can furnish medical supervision to the public 
schools only, while as a health measure the board of health can 
extend it to private schools as well. 

As a result of this discussion, let us see if we can construct a ra- 
tional scheme for the medical supervision of the school child. In 
so doing, statements will have to be made rather dogmatically, so 
as to avoid interminable explanation. The elements of a successful 
plan for the State of Massachusetts might be set forth as follows : — 
State Guidance. — In view of our 354 municipalities, large and 
small, it seems probable that real progress will be slow in caring for 
the health of the school child unless there is some measure of State 
guidance. This, it may be said in passing, is not the same thing as 
State control. Individual initiative and growth should be preserved 
as far as possible. The question then arises, should this State guid- 
ance center in the Public Health Department or in the Educational 
Department? Here we must differentiate between physical educa- 
tion, so called, and medical school examination. Physical education 
consists largely in teaching to children the simple rules of health, — 
how to exercise, sleep, eat, breathe, rest and play. For a long time 
to come this will have to be done by non-medical teachers, and of 
course should be a part of the regular school curriculum. There- 
fore physical education may be said to be a prime interest of the 
Educational Department. But it is also of the greatest interest to 
the Public Health Department, and must be co-ordinated with 
medical school examination. Hence the guidance of the State policy 
as regards physical education should be in the hands of the educa- 
tional department, which should consult with the Public Health 
Department as regards the broad health principles involved. 

When we come to medical school examination, on the other hand, 



conditions are reversed. Here the chief interest and responsibility 
should be with the Public Health Department, which should con- 
sult with the Education Department, especially in matters affecting 
school routine. 

Local Control. — What has been said of the distribution of State 
responsibility is equally true of local conditions. Both the local 
school committee and the local board of health have legal and moral 
responsibilities for the health of the child in the public school. At 
present, under the law, in all the towns and in most of the cities 
the actual administration of medical school inspection is in the 
hands of the school committees. This should not preclude free co- 
operation between the school committee and the board of health. 
In fact, anything less is inexcusably bad civic policy. It would be 
advisable to have this co-operation enjoined by an amendment to 
the law. 

Personnel. — Medical school inspection calls for a high degree of 
medical skill on the part of the school physician, and training and 
experience in medical and social work on the part of the nurse. Both 
doctor and nurse are essential to efficient control of school hygiene. 
Much has been said and written on the question of whole-time or 
part-time service on the part of the physician. Expediency usually 
dictates part-time service. At best, however, such service must be 
relatively unsatisfactory; especially is this true of a combination of 
general practice and school work. A general practice is a hard task- 
master. When people are sick they want a doctor at once, and it is 
for the doctor's interest to go at once. School work, being appar- 
ently less urgent, is pushed to one side. The job of school physician, 
properly understood, is a big enough one to take the whole of a 
man's best energies. 

The school nurse is almost always a whole-time worker; that is, 
she gives her whole time to some form of public health work-. Be- 
cause of this very fact she has an advantage over the part-time 
school physician. The latter is competing with other practicing 
physicians; the school nurse is in competition with no one, and so 
arouses less enmity. This is not true of the nurse who practices 
medicine by making diagnoses and advising treatment, a procedure 
which is always to be deplored. 

In the case of the school nurse, however, as in the case of the 
school physician, the exigencies of circumstances in many localities 
seem to make it necessary that the school nurse do other types of 
nursing as well. It is unfortunate if the other types must include 
bedside nursing. It happens almost invariably and inevitably that 
the bedside care of the sick sooner or later takes precedence in her 



8 

thoughts over the apparently less urgent care of the comparatively 
well school child. Nevertheless, the small rural community, for the 
present, at least, probably cannot get school nursing upon any other 
terms. In certain Massachusetts towns it would be well worth 
while to try the scheme of having several small towns employ a 
school nurse (as well as a school doctor) in common. A county 
school nurse is also a promising possibility, though this would neces- 
sitate enabling legislation. 

During the school summer vacation the school physician and 
school nurse can profitably be employed on other types of child 
welfare work. This is more easily arranged where the medical school 
work is in the hands of the board of health. 

One word may well be said here as to the number of school phy- 
sicians and nurses needed properly to carry on the work in a given 
community. This will, of course, vary with the type of population 
served and with the distances to be covered. The standards set up 
at the Child Welfare Conference at Washington serve as a good 
guide; namely, 1 school nurse for not more than 1,000 school chil- 
dren; a part-time physician with 1 full-time nurse for not more than 
2,000 children; or 1 whole-time school physician and 2 whole-time 
nurses for each 4,000 school children. 

School Examinations. — By statute in Massachusetts it is required 
that an annual examination be made of each school child. JThis 
examination is expected to be sufficiently thorough to detect any 
defect which would tend to prevent the child from getting the full 
benefit of his schooling. The average inspection which the school 
child undergoes falls miserably short of this. The child is entitled 
to a careful physical examination, embracing heart, lungs, nose and 
throat, sight and hearing, posture and especially nutrition. This 
examination should be done in private, and should include weighing 
and measuring. The latter phase of the examination should be re- 
peated at frequent intervals, — monthly, or even weekly under 
certain circumstances. Children found below normal should, of 
course, be the ones to get the more frequent weighing. Taking the 
height and weight may well serve as a rough test at the beginning 
of the year to pick out the pupils most in need of early intensive 
attention. 

The mental examination of the child is also indicated, though for 
the present it will probably be limited to the atypical or retarded 
child. 

Need of Co-operation. — One of the points most in need of em- 
phasis is that the supervision of the school child, whether from the 
point of view of medical school examination or physical education, 



9 

should be a joint affair on the part of the school authorities, health 
authorities and parents. Much of the friction arising in adminis- 
tration conies through a failure to recognize this. The school and 
health authorities must themselves co-operate whole-heartedly. The 
school doctor must co-operate with the supervisor of physical edu- 
cation, and vice versa. It is illogical and sometimes dangerous to 
inaugurate or continue physical exercise without physical examination 
to determine existing physical defects. It is futile to examine chil- 
dren without some provision for getting something accomplished 
when defects are discovered. 

The parent must not be overlooked in this scheme of things. She 
(it is usually the mother who responds) should be invited to be 
present when her child receives his annual physical examination. 
Both the school authorities and the parents will learn something 
from an interchange of ideas. Incidentally, much of the opposition 
to the physical examination of school children, seen in certain local- 
ities, would be obviated in this way. Such opposition is based 
largely upon misapprehension and ignorance rather than upon prin- 
ciple. Such a method takes a little longer, but shows greater ulti- 
mate results. 

Conclusions. — We may briefly summarize this discussion on school 
hygiene thus : — 

1. The medical supervision of school children and the teaching of 
the simple health habits are now recognized to be essential by all 
who have given any real thought to the subject of school hygiene. 

2. Both these matters are of vital concern to parents, to school 
committee and to board of health. 

3. Rules and regulations regarding both these phases of school 
hygiene should be made jointly by both education and health de- 
partments. 

4. Administration of medical school inspection should be the job 
of the health department; administration of physical education and 
teaching of health habits, that of the school department. 

5. Adequate supervision, as outlined above, calls for trained school 
physicians and nurses and teachers of physical education, and suf- 
ficient remuneration for these workers to enable the community to 
get efficient service. 

6. Careful physical examination should be followed by every ef- 
fort to get defects remedied. This means clinics or private medical 
care for the defective child, and physical education for the child when 
he is well. The defective child should be made well; the well child 
should be taught how to keep well. 



Gaylord Bros. 



Makers 



Syracuse 



N.Y. 



PAT. JAN. 21, 1908 



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